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Ask the Doctor: Tattoos and beauty are skin deep

The doctor gives advice on getting ink for endurance athletes

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Editor’s note: Dawn Richardson is a former member of the Verizon Wireless-Cervelo Women’s Cycling Team. She is a board-certified emergency medicine physician practicing at Roger Williams Medical Center in Providence, Rhode Island, and is a clinical instructor in emergency medicine at Brown Medical School.

Should I get that ink?

Dear Doc,
Do tattoos restrict sweat glands? Do they have any negative effect towards the cooling performance of the body? I am asking about a highly tattooed body, not just a few here and there.
— Chris Rossow in Colorado Springs

Dear Chris,
What might be regarded as a weird and quirky question at first blush is actually quite medically complex. It also opens the door for a broader discussion regarding tattoos and why skin care is so important to cycling.

First, here’s a background dermatology and immunology primer. The skin is the largest organ in the human body, composing 7 percent of total body weight. Among its many jobs is maintenance of body temperature, regulating water losses and keeping bacteria and chemicals out of the body by providing a protective barrier.

The skin is composed of the epidermis, dermis and hypodermis. The epidermis, the outermost layer, is about 1mm thick on average and is made up of five smaller layers. From inside to outside they are stratum basale, stratum spinosum, stratum granulosum, stratum licidum and stratum corneum. The stratum corneum and stratum licidum are composed of layers of dead skin cells. These layers protect the body from abrasions and foreign chemicals, flattening and drying as they come to the surface. Stratum basale pumps out columns of new skin cells towards the outer layers of epidermis. It adheres to the dermis along a wavy border.

A tattoo needle penetrates this dermal-epidermal junction to partway into the dermis. This completely disrupts the barrier function of the epidermis, causing a wound and depositing tattoo ink openly into the dermis. How the wound heals affects not only the quality of the tattoo, but also the quality of the skin function after the wound has healed.

The tattoo ink stays in place for years by tricking the body’s complex immune response. Think of tattoo needles and ink as a military operation. The immune system leaps to defend the body against a wound and ink invasion, thinking a bad infection is about to occur. The body is functioning properly by responding this way. Maybe that’s a bit of food for thought before you take on the needle.

Phagocytes are like Pac-Men. When tattoo ink is deposited in the dermis with the little buzzing needles, the body mounts an immune response with macrophages, phagocytes and mast cells. Macrophages and phagocytes are the rough equivalent of microbiological Pac-Men (or Ms. Pac-Men to be gender-equal), and literally eat and envelop the tattoo ink in an effort to contain the invasion of foreign material. (If you put a stethoscope on your new tattoo, you just might hear a faint wocka-wocka-wocka.)
As the damaged epidermis and dermis heal, granulation tissue and specifically dermal fibroblasts interlock the ink-containing phagocytes in a collagen network just beneath the dermis/epidermis junction. That’s how the ink stays put for years.

The coiled pink blobs in the cross-section pictured above are the sweat glands, which originate in the hypodermis, way below the superficial dermis placement of tattoo ink. The microscopic drainage tubing of the sweat glands, however, can theoretically be damaged by the tattoo wound and subsequent healing process.

The tubing goes right through the dermis and epidermis. I searched the medical and tattoo literature for a definitive answer on just how much sweat-gland damage occurs, and came up empty. I spoke with Tanya McKeehan from the American Academy of Micropigmentation. She insists that the dearth of medical information and research on such damage in tattooing is because there isn’t any. There are about 100 sweat glands per square centimeter of skin, so it would be hard to imagine that all are damaged. I suspect that many of them survive intact. Those that are damaged may not function at 100 percent when healed.

So to answer your question, I have to wager that some sweat gland damage may occur and it’s a matter of speculation just how much. A “full suit” tattoo would be more likely to have significant impact on the sweat glands’ ability to maintain body temperature. I would recommend having major work done in the off-season to allow the skin ample time to heal and train back up to maximum sweat-gland function before race season. Even with a full suit, there are many bare areas that have no ink at all and are completely undamaged.

The immune response to tattooing is no false alarm. Proper tattooing and aftercare are imperative, not only to prevent infection, but to make your tattoo look better and last longer. Please only get tattooed at licensed legitimate shops to reduce your chances of blood-borne diseases, including, but not limited to, HIV and hepatitis C. No private tattoo parties or Third World tats. Strict sterile technique is crucial to reducing the chance of cellulitis, a dangerous skin infection. The aftercare instructions of mild soap and water and topical antibiotic creams should be adhered to strictly.

As a physician, undergraduate psychology major and confidante to many cyclists, I’d also like to have a word about your choice of tattoos. This tattoo/piercing of Nerac.coms’ Adam Hodges Myerson is large and ornate, yet easily covered by team kit. This keeps even the most conservative sponsors happy.

Most America tattoo artists are bound by ethical codes not to tattoo the face as this often interferes with customers’ ability to find work. Think very carefully before considering a facial tattoo like David Clinger’s Maori-like tat. After 20 years in the ER I also recommend thinking very carefully about having your current lover’s name tattooed on your body. Sure, true love lasts forever, but broken hearts are really quite burdensome, especially when coupled with expensive tattoo removal.

I’m old and grumpy enough to observe two recent skin-care fads in cold weather cycling that I find puzzling and medically counterintuitive. The first is bare legs in the snow. I was a junior back when disco was king and all we had to go by was the CONI (Italian Olympic Committee) cycling manual. The good book strictly forbade riding in bare legs below 70 degrees Fahrenheit. These are words to live by, even with the bad English translation. Your skin can only do so much temperature regulation. Cold, bare legs make it harder for your body to maintain core temperature and prevent hypothermia.

Second and even stupider in my opinion are vasodilating balms in a misguided effort to keep bare legs warm when underdressed. By using heat balms you are dilating the blood vessels, thus losing more core temperature. The physiological response to cold exposure is restricting blood flow to the skin and extremities to preserve core temperature. Heat balms to bare cold legs do the opposite and further threaten core temperature. Cold hands and feet and rapidly worsening brain function means you are underdressed, not that you should slap on more wintergreen and capzasin oil and accelerate core hypothermia. There is no such thing as bad weather, just bad clothing. Hypothermia doesn’t make you manly and it sure as heck won’t win a race.

I also have a strong medical opinion about suntans and sunburns in particular. Don’t get them. Either train in the morning and evening or glop on sports sunscreen to exposed areas half an hour before you head out the door to allow the sunscreen a chance to penetrate the outer epidermal layers. Barring bad luck, bad genetics or bad judgment you should expect to live to 100 years old. To be taken down early by melanoma or squamous cell carcinoma is pure foolishness. Sunburns also inhibit the proper cooling function of the skin in the short term. If you must succumb to vanity I recommend a fake bake cream such as Jergens Natural Glow or L’Oreal Sublime Bronze. All fake bakes have a nasty skin feel so I’d use them right after a shower and many hours before the next sweaty training ride.

One last word on skin care: be nice to your skin and it will be nice to you. You want a nice plump stratum corneum to help regulate skin temperature. Right after you shower there is a ton of free moisture available right on your skin waiting to be locked in by a light layer of moisturizer. Half an hour later, especially this time of year, you are itching and dry if you’ve missed the boat with the moisturizer. My favorite dermatological moisturizers are Lubriderm and Eucarin. Right after a shower is also a great opportunity to use a combination sunscreen/daily moisturizer with SPF15 and kill two birds with one stone.

If you don’t have sensitive skin you can get fancy with moisturizers that contain fun ingredients like shea butter and glycerin. Blot (don’t rub) dry after you shower and put on moisturizer right away. Your skin will thank you by keeping you warm when it’s cold and cool when it’s hot.

Thanks for reading, and keep the rubber side down, Dawn.

Important note: The information provided in the “Ask the Doctor” column is not medical advice. The information provided on this public web site is provided solely for general interest of the visitors to this website. The information contained in this column applies to general medical practice and may not reflect current medical developments or be interpreted as medical advice. Understand that reading the information contained in this column does not mean that you have established a doctor-patient relationship with Dr. Dawn Richardson. Readers of this column should not act upon any information contained in the website without first seeking medical advice from their personal physician.